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pth101unit7
medical records
| Question | Answer |
|---|---|
| reviewing a pt's medical record, looking for new orders/changes in pt status are parts of the inital ___ ____ review. a.patient status b.PT intervention c.medical record d.dr order | medical record |
| what form will include Patients name age, marital status, type of insurance admitting diagnosis date of admission and MD? a.medical b.identification c.history d.physician orders | identification |
| what form will a pt sign for surgeries,procedures and may have advance living will or medical power of attorney a.surgery report b.medical record c.progress d.consent | consent |
| what would include the ROS, MD examination, proglem list primarary/secondary Dx, and POC? a.medical report b.progress notes c.physician orders d.Hx and Physical exam | Hx and physical exam |
| H&P stands for? | history and physical |
| how would a MD proceed with evaluating a pt for a Rehab center? a.consent and release form b.physician orders c.consultation d.specialized report | consultation |
| where do healthcare providers and the MD write comments about the pt condition and to communicate to other healthcare providers? a.medical report b.physician's orders c.progress notes d.specialized reports | progress notes |
| where would you find all orders for tests, medication, PT, nursing, diet and Rx? a.consultations b.consent and release forms c.medication record d.physician's orders | physician's orders |
| where would you find the discription of anesthesia, and transcribed description of the Sx? | surgery report |
| what holds every medication and nursing medication sheets? a.specialized reports b.medication record c.progress notes d.medical record | medication record |
| x-ray reports, lab reports,imaging reports and EKG's would be included in what? a.consent reports b.consultations c.physician's orders d.specialized reports | specialized reports |
| heart rate, tempature, blood pressure and respiratory rate would be included in the daily? a.progress reports b.nurses notes c.specialized reports d.vital signs | vital signs |
| where would you find the intial PT eval, brief Hx, subjective comments, LTG, and may be in a SOAP format? a.physician report b.consultation report c.physical therapy section d.medical records | physical therapy section |
Created by:
heatxfer
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